—Blue Oyster Cult
The designers of the hospital value-based purchasing (HVBP) program sought to include outcomes measures in 2014, and when they did, mortality was their choice. Specifically, HVBP for fiscal-year 2014 (starting October 2013) will include 30-day mortality rates for myocardial infarction, heart failure, and pneumonia. The weighting for the mortality domain will be 25% (see Table 1).
To review the requirements for the HVBP program in FY2014: All hospitals will have 1.25% of their Medicare inpatient payments withheld. They can earn back none, some, all, or an amount in excess of the 1.25%, depending on performance in the performance domains. To put it in perspective, 1.25% of Medicare inpatient payments for a 320-bed hospital are about $1 million. Such a hospital will have about $250,000 at risk in the mortality domain in FY2014.
Given the role hospitalists play in quality and safety initiatives, and the importance of medical record documentation in defining the risk of mortality and severity of illness, we can be crucial players in how our hospitals perform with regard to mortality.
Focus Areas for Mortality Reduction
Although many hospitalists might think that reducing mortality is like “boiling the ocean,” there are some areas where we can clearly focus our attention. There are four priority areas we should target in the coming years (also see Figure 1):
Reduce harm. This may take the form of reducing hospital-acquired infections, such as catheter-related UTIs, Clostridium difficile, and central-line-associated bloodstream infections, or reducing hospital-acquired VTE, falls, and delirium. Many hospital-acquired conditions have a collection, or bundle, of preventive practices. Hospitalists can work both in an institutional leadership capacity and in the course of daily clinical practice to implement bundles and best practices to reduce patient harm.
Improve teamwork. With hospitalists, “you started to have teams caring for inpatients in a coordinated way. So I regard this as [hospitalists] coming into their own, their vision of the future starting to really take hold,” said Brent James, coauthor of the recent Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Partly, we’ve accomplished this through simply “showing up” and partly we’ve done it through becoming students of the art and science of teamwork. An example of teamwork training, developed by the Defense Department and the Agency for Healthcare Quality and Research (AHRQ), is TeamSTEPPS, which offers a systematic approach to cooperation, coordination, and communication among team members. Optimal patient resuscitation, in-hospital handoffs, rapid-response teams, and early-warning systems are essential pieces of teamwork that may reduce mortality.
Improve evidence-based care. This domain covers process measures aimed at optimizing care, including reducing mortality. For HVBP in particular, myocardial infarction, heart failure, and pneumonia are the focus.
Improve transitions of care. Best practices for care transitions and reducing readmissions, including advance-care planning, involvement of palliative care and hospice, and coordination with post-acute care, can be a key part of reducing 30-day mortality.
Accurately capturing a patient’s condition in the medical record is crucial to assigning severity of illness and risk of mortality. Because mortality rates are severity-adjusted, accurate documentation is another important dimension to potentially improving a hospital’s performance with regard to the mortality domain. This is one more reason to work closely with your hospital’s documentation specialists.
Don’t Be Afraid...
Proponents of mortality as a quality measure point to it as the ultimate reflection of the care provided. While moving the needle might seem like a task too big to undertake, a disciplined approach to the elements of the driver diagram combined with a robust documentation program can provide your institution with a tangible focus on this definitive measure.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].